Admission Details for Patient: Richard Williams (2504)
Gender: Male Age: 22
Marital Status: Single Religion: Protestant
Occupation: Labourer
Address: Llanddaniel Fab, Anglesey
Date of Admission: October 23, 1875
Date of Death: September 28, 1876
Cause of Death: Pneumonia
Disease: Acute mania
Supposed Cause: Fall in a quarry
Medical Certificate:
Delusions, fever, high pulse, threats, hallucinations, self destruction, injury to others, wandering, cleptomania. Imprisoned twice - the last time for a year. Communicated by his mother and Mr Hughes, Relieving Officer. Lewis Jones, Menai Bridge.
Approximate duration of present attack: not stated
Number of Previous Attacks: 1
Number of Previous Admissions: 0
Number of Subsequent Admissions: 0
Total Number of Admissions: 1
Relatives affected: All mother's relations and herself weak-minded
Number of Previous Attacks: 1
Epileptic: No
Suicidal: Yes, threatened but not attempted
Dangerous: Not certain
Clean Habit: Yes
Food Refusal: No
Sleep Habit: None last night
Destructive Habit: Torn a hat
Disposition: Sober, abstainer, Good Templar
Education: Reads
Physical/Mental State at Examination: Previous bodily health good but scrofulous. Large scars from scrofula under left lower jaw. Free from bruises, tall and thin, nervous temperament. Was in jail for 12 months and left 8 months since for stealing a horse. He was not sane at the time according to the Relieving Officer. Fell on his head 3 years ago and became insane soon after. Incoherent, talking loudly to himself and paying but little attention to anyone.
Current Diagnosis: Mental Disorder due to brain damage/physical disase (F06.8)
Case Notes
1875 Oct 27 - Still noisy and incoherent.
Given Chloral.
Oct 30 - Much better, speaks only when spoken to and talks more rationally.
Whistled a great part of last night.
Dec 16 to March 1 1876 - no improvement.
March 8 - Has become much worse the last few days, has taken to tearing his clothes and become dirty. Wears a tick suit, is silent and depressed.
Apr 5 - Is apparently becoming demented, is dirty and untidy and very incoherent. Aug 10 - Bodily health rather feeble.
Sept 5 - Is in bed today suffering from double pneumonia at bases. Amm. Carb and Senega (Snakeroot).
Sept 7 - The temperature has rather decreased but his abdomen is becoming tumid. Breathing very short but no cough. Sept 9 - His legs have much swelled and are covered with purpura haemorrhagica as well as his body.
He does not cough but his breathing is much choked and the chest is becoming more resonant. Pil. Hydrarg. (mercury based purgative).
Sept 10 - The bowels have acted freely.
Lungs clearing more.
Sept 12 - The swelling of abdomen and legs have much decreased and the purpuric patches have to a great extent gone.
Sept 15 - Dropsy ceased but he is very low. Is taking Iron and Calumba (a bitter for dyspepsia) and Brandy with extras.
Sept 20 - Has been slowly improving till today when his temperature rose to 102 and his breathing became short, his skin dry and hot. Sept 21 - Has begun to cough and spit green offensive mucous.
There is dulness at right base behind and probably a cavity. Sept 23 - Is becoming more feeble and now refuses his food for the first time. Sept 24 - The symptoms continue and he is become more feeble.
Sept 28 - Died this morning at 5 am.
Medications/Treatments: Chloral gr xxv, Ammonium Carbonate and Senega (Snakeroot) expectorant, Pil. Hydrarg gr x, hydrargyrum (mercury - purgative), Iron and Calumba (simple bitter for atonic dyspepsia), Tick suit
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